Background

According to the Centers for Disease Control and Prevention (CDC), 42.4% of the United States population was classified as obese in 2017-2018. The prevalence of severe obesity (BMI>40) continues to increase at a significant rate. Patients with severe obesity, super, or super-super obesity (defined as BMI>60) have been shown to be at greater risk for all-cause mortality. Due to a higher incidence of venous thromboembolism, extended chemoprophylaxis is often recommended post-operatively in this patient cohort. We present a case of a patient with super-super obesity (BMI 77.2) who underwent an uncomplicated sleeve gastrectomy and subsequently developed a bleeding complication while on low-molecular-weight heparin (LMWH). Imaging revealed a large hyperattenuating collection in the central mesentery without active extravasation. In the intensive care unit, the patient was managed non-operatively with fluid resuscitation and transfusion of red blood cells. Although staple line bleed remains on the differential, the location and presentation of the hematoma suggests that being in the supra-therapeutic range of LMWH may have been the etiology of the hemorrhage. Several major bleeding events have been reported with LMWH. Ideal monitoring of chemoprophylaxis in those with a BMI above 60 can prove difficult and a standard dosage remains undefined. We aim to review the risks of LMWH dosing in the population of individuals with super-super obesity.